General Resources
The following are general resources widely used in the social work profession. For location-specific information on resources that are not available nationwide, please research each resource within the relevant area.
Housing & Shelter
211.org
Local referrals for emergency shelter, housing support, and basic needs.
Recuperative Shelters
are specifically for patients who have been in the hospital due to a illness, injury, or need for surgery , are homeless, and need additional time to recover prior to going back to the community.
At recuperative shelters patients are allowed to have oxygen, if needed, and they are allowed to receive home health. Usually, referrals made to recuperative shelters must come from the hospitals and are subject to availability.
General Shelters
General shelters are for the homeless population at large. General shelters are self-referral and usually involve waiting in line or getting on a waiting list. As the social worker you can make calls to the shelters to inquire about availability and possibly a bed hold. Getting bed holds is all about the relationships you build with community partners.
Domestic Violence Shelters
Domestic Violence Shelters – Local or national programs (e.g., National Domestic Violence Hotline: 800-799-SAFE). Know your local domestic violence resources and how to connect patients in crisis to them.
Drop-in Centers
Drop-in centers are places that allow homeless induvial to come and shower, relax, and/or receive mail. This may not be a resource in all areas so please research local drop-in centers when you arrive to or new assignment or before.
Housing & Urban Development
HUD (Housing & Urban Development) – Subsidized housing info, Section 8, housing rights, homelessness prevention programs.
- Section 8 (Housing Choice Voucher Program) is a very popular resource that generally has waiting lists that range from months to years. This program offers its recipients vouchers that can be used for different housing opportunities based on their income. *Research your local housing authority for more information.
-Public Housing is a housing program like Section 8; however, it does not offer a voucher that can be used for different housing opportunities. Public housing is often apartment complexes that are income based. Once an individual moves out of an income-based apartment they will no longer have income-based rent, unless they move to another income-based community. Due to the nature of the low rent, waiting lists for these communities can range from months to years. *Research your local housing authority for more information
Medicaid
Medicaid – State health insurance for low-income individuals. Medicaid may have a different name in each state (ex. MediCal, Healthy Blue). It is imperative to know the name of it in your state.
- Know the different types of Medicaid offered in your state. While all states offer Medicaid as a form of medical insurance, it's important to note that Medicaid comes in various forms. Some programs specifically cover services like long-term care, assisted living, or residential care facilities. These options vary by state.
- HealthCare.gov – Marketplace enrollment and subsidy eligibility. Many of the patients we serve will not need to go this route to obtain insurance, but if they do this marketplace, is a great resource. Depending on your facility, if a patient is admitted without insurance they should automatically be referred to financial services. If you are unsure of this process, please consult with your leadership.
Cobra
COBRA is a federal insurance program that allows individuals and/or their family members to remain covered under employer sponsored plans temporarily in the event of job loss due to a qualifying event.
Healthcare & Insurance
Community Health Clinics
Community Health Clinics (FQHCs) – Low-cost or sliding-scale care. It is important to have a list of the clinics in your community and surrounding areas to better assist patients with follow up care when they are discharged from the hospital.
Prescription Assistance Programs
Prescription Assistance Programs – GoodRx, NeedyMeds, Partnership for Prescription Assistance.
- Elloquis is a medication that is often prescribed to patients on the cardiac units, but not exclusively. This medication on average can start at $600 without insurance. Surprisingly, this pricey medication is not covered by all insurances so, it is very important to know the coupons and resources available to assist with this medication. Elloquis has a coupon that can be used at the pharmacy. In general, these coupons can be found at the pharmacy, doctor’s offices, directly from the manufacturer’s website, and many other places. Please consult with your team to locate them in your hospital.
- Bristol Myers Squibb Patient Assistance Foundation is a foundation that offers prescription assistance on several medications that are very expensive and not covered by insurance. This program has specific eligibility requirements so, review the website to determine appropriateness for your patients.
- Manufacturer websites often offer medication-specific coupons, so it's worth checking them when prescription assistance is needed.
- Medication vouchers are offered as a one-time assistance through the hospital for patients who do not have insurance at the time of discharge; to ensure a safe discharge and lower the risk of readmission. The pharmacies used are contracted with the hospital. *This is a health system specific resource and may not be available at your facility. Speak with your team to determine.
Medicare
Part A Hospital Insurance
Covers:
- Inpatient hospital stays
- Skilled nursing facility care (short-term)
- Hospice care
- Some home health care
Part B – Medical Insurance
Covers:
- Doctor visits
- Outpatient care
- Preventive services (e.g., screenings, vaccines)
- Durable medical equipment (like walkers, oxygen equipment
Ryan White HIV/AIDS Program
This is a Paragraph. Click on "Edit Text" or double click on the text box to start editing the content andRyan White HIV/AIDS Program is a program that provides a comprehensive system of HIV primary medical care, medications, and essential support services for low-income people with HIV. These resources are provided through funding given to specific clinics in local areas. To determine which clinics in your area utilize the Ryan White HIV/AIDS Program review the website click on HIV Care > Find a Provider then enter the local zip code. make sure to add any relevant details or information that you want to share with your visitors.
Financial & Basic Needs
SNAP
SNAP – Food assistance. There are many terms for SNAP in different states and in different communities. In California SNAP is referred to as CalFresh, in Arizona it is referred to as a Quest Card, in Michigan it is referred to as Bridge Card, know the term in your state. In some communities SNAP is referred to as, “EBT” or “food stamps.” Though food stamps is well known term, when completing initial assessments, I call SNAP benefits by the state name. Usually, patient rooms are not private and as an added level of privacy I believe it is more appropriate.
WIC
WIC – Nutritional aid for pregnant/postpartum women and young children
Food Pantries
Food pantries, soup kitchens, farmer’s markets that accept SNAP benefits are all state and county specific, but great resources to know.
Home Delivered Meals
Meals on Wheels (MOW) – is a federally funded nutrition program that is managed by individual communities. MOW is usually coordinated through senior programs but not exclusively. Many churches run MOW programs for their communities. To assist your patient with getting established, research the local MOW program in your area.
Mom’s Meals is a privately owned company, and patients can get connected to the program through their Area Agency on Aging, Insurance, or you as the social worker can make the referral. This program is not available in Hawaii or Alaska.
Temporary Assistance for Needy Families
TANF (Temporary Assistance for Needy Families) – Cash aid programs. Other cash assistance programs might be called by a different name in your state. For example, General Assistance or General Relief. TANF is funded at the federal level, while cash assistance is managed at the state level and can have county specific eligibility requirements. Please refer patients to their local social services office or to the state’s government website to apply.
State Disability Insurance
State Disability Insurance (SDI) is a disability program that is managed at the state level. There is a specific criterion that a patient must meet to qualify for SDI benefits, if approved the recipient will receive partial wage replacement. This is a program that must be paid into to qualify. This benefit is only available in five states: California, Hawaii, New Jersey, New York, and Rhode Island.
Social Security Disability Insurance
Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) are federal disability programs. Each program has specific criterion, which can be found on the national website ssa.gov. Patients can apply online for faster service visit their local office, or call the number or the website to apply.
Family Medical Leave Act
Federal Family and Medical Leave Act (FMLA) is a federal program that allows individuals to take a leave of absence from work to care for a loved one with a serious health condition. Some states offer Paid Family Leave (PFL) which is a benefit that will offer payments for individuals who need to be off work to provide care for care for a loved one, bond with a child, or military related. This benefit is only offered in 13 states, plus Washinton DC: California, Colorado, Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, and Washington.
Low Income Home Energy Assistance Program
Low Income Home Energy Assistance Program (LIHEAP) is a program that supports low-income families with reducing their energy costs.
Emergency Financial Assistance
Emergency assistance is offered through many local agencies. When it comes to emergency help a great place to start is the Department of Health and Human Services or social services, but assistance available can be state specific. Salvation Army, Catholic Charities, Jewish Family & Children’s Services, and Modest Need are national organizations that can assist in times of crisis.
988
988 Suicide & Crisis Lifeline – Call or text for mental health emergencies. Crisistextline.org is a great place to find additional mental health resources.
NAMI
NAMI (National Alliance on Mental Illness) – Education, peer support, and advocacy.
Mental Health & Crisis Support
SAMHSA
SAMHSA.gov – Substance use and mental health resource locator. It is very important to know the process to enter treatment at your local substance abuse treatment and detox centers. If a patient is motivated to receive support with their substance abuse prior to discharge, it is most ideal to make it a smooth transition from the hospital to treatment. Patients must take the first step by calling to complete the intake, but social workers can support with next steps.
CRU/CSU
Crisis Stabilization Units/Crisis Residential Units may vary based on state, but if working with psych patients is apart of your role these are must know resources. These resources are for individuals who are in immediate mental health crisis.
Insurance Companies
Insurance companies provide mental health support to their recipients. If patients are unsure of what providers are in their network, encourage them to call the customer service number on the back of their card.
Psychology Today
Psychology Today is a website that allows those in search of a therapist to look for providers who take their insurance and are skilled in their specific need.
EAP
Employee Assistance Program (EAP) is an employer sponsored mental health resource, which usually allows a certain number of free sessions.
CPS
Child Protective Services (CPS) Contact CPS to report any abuse, neglect, or exploitation of a child. Research the local number in your area and determine if there is an online intake form. In some counties you must call to report AND complete the intake form online. Ask your team if the online intake can satisfy both requirements; this is county specific.
Early Education
Head Start is a federally funded program that primarily supports children from low-income families. These programs are ran at the local level and there is no set point of contact.
Early Intervention in special education involves offering support and services to infants and toddlers—usually from birth to age three—who are experiencing developmental delays or have disabilities. These are federally funded programs that are managed at the local level with no set point of contact.
APS
Adult Protective Services (APS) Contact APS to report any abuse, neglect, or exploitation of a vulnerable adult. The standard description of a vulnerable adult is anyone who has a physical or mental disability that enables them from caring for themselves. Review your state’s policy and determine what is appropriate. Research the local number in your area and determine if there is an online intake form. In some counties you must call to report AND complete the intake form online. Ask your team if the online intake can satisfy both requirements; this is county specific.
Children & Families
AAA
Area Agency on Aging (AAA) is funded federally, at the state level, and local/private contributions. AAA is a hub and a great resource for patients and families who are wanting more resources in the community. AAA can provide information and assistance, care coordination, and caregiver support.
Caregiving
Caregiving agencies are available in every state, city, and town. It is important to know the top ones in your area, those that support low-income families, and any assistance programs that might be available to assist with paying for caregivers.
In Home Supportive Services (IHSS) is a MediCal benefit that allows MediCal recipients who need caregivers to hire help to meet their care needs (personal care, errands, light housekeeping, transportation, etc.) and their employee will be paid for by the program. This program is funded federally, by the state, and locally. IHSS is a California specific program by name; however, other states have a resource like this program for recipients of MediCaid. Familiarity with this resource is essential.
Placement Locator can be an agency or a local individual/company. This resource assists families and patients with finding long term care placement. This is often a free resource, and they will earn commission from the communities.
Transportation
Transportation can be provided by many resources in the community depending on the need.
- Public transit systems are required to have a separate program that provides transportation to individuals who cannot ride fixed routes due to a medical condition or disability.
- Medicaid offers its recipients a transportation benefit to and from medical appointments and home after being discharged from the hospital.
- Case management departments usually have bus passes available to offer patients.
- Depending on the hospital there may be a system that allows the use of Lyft or Uber Health to transport patients home after being discharged from the hospital, if there is a financial assistance need.
ALL
- Catholic Charities / IRC (International Rescue Committee) – Immigration support, case management.
- Local Consulates – For international travel, documentation, and repatriation.
- Undocumented patients may be allowed to receive some social services. Review your state’s policies to determine how to best support those patients.
Immigration & Refugee Services
Additional Resources
Human Trafficking
National Human Trafficking Hotline- 1(888)-373-7888 or text “233733”. This is a must know resources for human trafficking. Also, please research the local agencies in your area that are actively working to stop human trafficking and have additional resources to support victims.
Hotel
Hotel Resources. Some hospitals have relationships with local hotels to support families who may need to stay in town to be near their loved one. Talk with your leadership/team about what your hospital offers.
Used DME
Used DME. Durable medical equipment can be expensive and not all items are covered by insurance. Determine if there is a place that as free, used DME in your area or thrift stores that have items at a lower cost.
Legal Aid
Legal Aid. Know the contact information for the local legal aid office and know what services it assists with. Generally, legal aid can assist with disability applications, immigration issues, estate planning, issues relating to domestic violence, advance care guidance, etc. What services are offered can be county specific.